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Key words: common peroneal nerve, motor latency, compound muscle action potential amplitude, cerebrovascular accident,
drop foot
Abstract
Background: Common peroneal neuropathies, usually located
at the fibular head, are one of the causes of drop foot, a condition
often evaluated in the electromyography laboratory.
Objectives: To study the motor conduction properties of the
common peroneal nerve and its branches of distribution in patients
with paralyzed drop foot, several weeks after their first stroke,
assuming that its inversion position can cause neuropathy around
the fibular neck.
Methods: We performed peroneal nerve conduction study on
76 legs of 38 patients, 1273 days after their first stroke. All the
patients had flaccid drop foot on the involved side. The stimulating
electrode was placed at the postero-lateral aspect of the fibular
neck. Motor nerve conduction latency and compound muscle action
potential amplitude were measured along the proximal part of the
deep and the superficial peroneal nerve, comparing the paralyzed
to the sound leg. Paired sample t-test and paired t-test were used
to compare the nerve conduction properties between the sound
and the paralytic leg. The linear liaison between the two legs was
determined by Pearson coefficient and the test based on it.
Results: The differences between motor conduction latencies and
between CMAP amplitudes, comparing the paralyzed to the sound
side, recorded in both the deep peroneal nerve and the superficial
peroneal nerve, were statistically significant (P < 0.05).
Conclusions: It seems that the permanent equino-varus
position of the paralyzed foot might affect common peroneal nerve Figure 1. Foot in inversion position
conduction properties at the level of the fibular neck by demyelination,
axonopathy, or both. Possible reasons for these pathological changes
are nerve traction or nerve compression, but temperature changes The common peroneal nerve is injured more frequently than
in the paralytic leg should also be considered. Ankle-foot orthoses either of its branches alone. In fact, common peroneal neuropathy
can be prescribed for prevention or correction of deformities of the
foot and ankle and reduction of the weight-bearing forces.
is the most frequent lower extremity mononeuropathy. The CPN
IMAJ 2007;9:866869
can be injured by a stretch injury or by direct compression. Most
peroneal neuropathies occur at the knee level around the fibular
neck. Compression of the CPN at this level may cause pain and
The common peroneal nerve is a continuation of the sciatic paresthesia in the lateral aspect of the leg and the dorsal aspect
nerve, originating from nerve roots L4, L5, S1 and subdivided of the foot, as well as paresis of the foot extensor and pronator
under the fibular head as: muscles and the toes extensor muscles, also known as drop
Deep peroneal nerve, which supplies the muscles tibialis foot [1,2]. People suffering from severe or even mild ankle sprain,
anterior, extensor digitorum longus and brevis, extensor caused by inversion movement of the foot, reveal a high lesion
hallucis longus (motor) and the first web space of the foot of the peroneal nerve around the fibular neck [3-10].
(sensory). The present study was undertaken to investigate whether
Superficial peroneal nerve, which supplies the muscles a continuous inversion position of the paralyzed foot, seen in
peroneus longus and brevis (motor) and the dorsal part hemiplegic patients after acute stroke and imitating the foot
of the foot (sensory). position during ankle sprain [Figure 1], causes the same lesion.
Our objective was to study the motor conduction properties of
* Presented at the 55th annual conference of the Israeli Association of the common peroneal nerve and its branches of distribution in
Physical and Rehabilitation Medicine.
CMAP = compound muscle action potential CPN common peroneal nerve
hemiplegic patients with drop foot after their first stroke. The helpful in determining the conduction properties of the peroneal
conduction properties of motor nerve fibers in the peroneal nerve nerve so that the diagnosis of paralysis can be made in the
are usually calculated from small distal muscles [11], but it may presence of atrophy of the extensor digitorum brevis.
be difficult to measure peroneal nerve velocity if the extensor
digitorum brevis is atrophied, as in our patients. In this situation Statistical analysis
the latency and the amplitude can be calculated by recording Paired sample t-test and paired t-test were used to compare
the compound muscle action potential in a proximal muscle the nerve conduction properties, i.e., motor latency and CMAP
such as the tibialis anterior or the peroneus longus, by a simple amplitude, between the sound and the paralytic leg. The linear
technique that enables the examiner to test more functional correlation, comparing the different parameters between the two
muscles than the extensor digitorum brevis. legs, was determined by Pearson coefficient and the test based
on it.
Patients and Methods
The study was a retrospective analysis of data on patients Results
hospitalized in our rehabilitation department between the years Motor nerve conduction latencies in the deep peroneal nerve,
1998 and 2004. We routinely perform nerve conduction tests on registered in the tibialis anterior muscle, were longer in the
all patients who have a drop foot after stroke. Motor conduction paralytic side than in the sound side (paired sample t-test, P
studies for both deep and superficial peroneal motor nerve were < 0.001). Motor nerve conduction latencies in the superficial
tested in 76 legs of 38 adult patients after their first stroke who peroneal nerve, registered in the peroneus longus muscle, were
had hypotonic drop foot on the involved side. Their mean age also longer in the paralytic than in the sound side (paired t-test,
was 65 9 years (range 4380 years). The test was done 1273 P < 0.001) [Table 1]. The CMAP amplitudes were higher in the
days after their first-time stroke (mean 38 19). All patients had sound than in the paralytic in both the tibialis anterior muscle
complete paralysis of the foot and toes extensor muscles at the (paired t-test, P = 0.031) and the peroneus longus muscle (paired
time of the examination, when they were asked to contract them t-test, P = 0.0105) [Table 2].
in a lying and sitting position. Exclusion criteria were previous We found a low intensity linear liaison (r = 0.266) with regard
stroke, neuromuscular disease, radiculopathy or peripheral nerve to the difference between latencies of the two legs in the tibialis
injury in a lower limb, polyneuropathy, and diabetic neuropathy. anterior muscle and the difference between latencies of the two
The plantar flexion and inversion position of the paralyzed legs in the peroneus longus muscle. The liaison was determined
foot was not corrected by an elastic band at least until our nerve by Pearson coefficient and the test based on it (P = 0.053). The
conduction test. Some of the patients were wheelchair-dependent. significance is that as the difference between the latencies in
When the other patients exercised in the physiotherapy institute, the tibialis anterior muscle increase, the same difference in the
the involved foot was attached to the ankle by a strap in a neu- peroneus longus muscle increases concomitantly. Low to moder-
tral position in order to facilitate walking and even heel strike at ate intensity linear liaison (r = 0.434) was also found regarding
the start of the stance phase. the difference between the two legs CMAP amplitudes in the
The study was performed in a warm room and the tempera- tibialis anterior muscle compared to the same difference in the
ture was maintained at about 23C. Skin temperature was not peroneus longus muscle. The liaison was determined by Pearson
measured due to technical reasons. Patients were either lying coefficient and the test based on it (P = 0.003). No linear liaison
in bed or seated on a wheelchair with their legs propped on a was found between the time passed since onset of the stroke
regular chair. The tests were done following the method described and the difference between the two legs with regard to motor
first by Devi et al. [12]. For the proximal deep and superficial latencies and CMAP amplitudes. No differences were found in
peroneal motor nerve conduction, the stimulating cathode was motor nerve conduction latencies and CMAP amplitudes, between
placed at the posterior-lateral aspect of the fibular head. The people examined less than 32.5 days or more than 32.5 days
point for the recording surface electrodes was placed 8 cm from after occurrence of the stroke (median 32.5 days).
the cathode over the tibialis anterior in the first test and over
the peroneus longus in the second test. The reference electrodes Table 1. CMAP latency recorded in the tibialis anterior and
were secured respectively over the tendons of the tibialis anterior the peroneus longus muscles
and peroneus longus at the ankle [Figure 1]. All patients were Sound foot Paralyzed foot P
studied on a Nicolet Viking NT electromyography machine. The Tibialis anterior 3.25 0.35 3.6 0.48 < 0.001
electrical nerve stimulation level was 175 volt, well tolerated by Peroneus longus 3.57 0.45 4.11 0.53 < 0.001
all the patients, and the stimulator pulse duration of square
wave was 0.1 msec. The latency was measured from the stimulus Table 2. CMAP amplitude recorded in the tibialis anterior and
artifact to the onset point, and the amplitude was determined the peroneus longus muscles
from baseline to the highest negative peak [12-15].
Sound foot Paralyzed foot P
Results of the paralyzed leg were compared to those obtained
Tibialis anterior 5.05 1.94 4.4 1.89 < 0.031
in the sound leg. Means and standard deviations of the laten-
Peroneus longus 4.96 1.84 4.30 2.12 < 0.0105
cies and amplitudes were calculated. This method is particularly
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15. Buschbacher RM. Reference values for peroneal nerve motor Arch Neurol 1978;35:3603.
conduction to the tibialis anterior and for peroneal vs. tibial 21. Ragnarsson KT. Lower extremity orthotics, shoes, and gait aids.
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roneal nerve sheath after distal torsional fractures and inversion Functional Rehabilitation of the Lower Limb. Philadelphia: WB
ankle sprains. J Bone Joint Surg 1966;48A:148495. Saunders, 1997:20543.
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Bahri H. Une etiologie rare de paralysie du nerf sciatique Correspondence: Dr. A. Tsur, Dept. of Rehabilitation, Western Gal-
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Capsule
Limits of vision
What are the limits to the visual information that can be color, per visual scene. The results are interpreted within the
consciously accessed by a human being at any one time? framework of labeled Boolean maps, which postulates that
Huang et al. analyzed single momentary acts of conscious people can attend to multiple locations simultaneously, but
perception specifically with respect to location and color of only a single feature.
briefly presented visual stimuli. They found that we can be Science 2007;317:823
aware of more than one location, but not more than one Eitan Israeli
Capsule
Sexual abstinence-only programs to prevent HIV infection
Underhill and co-authors examined the effects of sexual absti- about 15,940 American youths. All outcomes were self-reported.
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high income countries. Two reviewers independently applied of unprotected vaginal sex, number of partners, condom use, or
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by consensus and referral to a third reviewer. Randomized and follow-up (sexually transmitted infections, frequency of sex) and
quasi-randomized controlled trials of abstinence-only programs long-term follow-up (sexually transmitted infections, pregnancy)
in any high income country were included. Programs aimed to compared with usual care, but the findings were offset by trials
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